Active NPI
Jenna Pederson
- Physical Therapist
- Detroit Lakes, MN
National Provider Identifier
1912377623
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 9146
- Practice address
- 1027 Washington Ave
Detroit Lakes, MN 56501-3409 - Phone
- (218) 847-5611
- Fax
- (218) 844-2444
- NPI assigned
- Oct 7, 2015
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 9146 | MN | Primary |
Addresses
Primary practice location
1027 Washington Ave
Detroit Lakes, MN 56501-3409
Mailing address
PO Box 6001
Fargo, ND 58108-6001
Phone (701) 364-8000
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1733 | ND | MD | Speech-Language Pathologist |
| 9146 | MN | MD | Medical Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1444176000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1444176000000",
"number": "1912377623",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 6001",
"city": "FARGO",
"state": "ND",
"postal_code": "581086001",
"telephone_number": "701-364-8000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1027 WASHINGTON AVE",
"city": "DETROIT LAKES",
"state": "MN",
"postal_code": "565013409",
"telephone_number": "218-847-5611",
"fax_number": "218-844-2444"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PEDERSON",
"first_name": "JENNA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2015-10-07",
"last_updated": "2015-10-07",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "MN",
"license": "9146",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Detroit Lakes, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 7, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.